Nazareth Living Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided with such care, consistent with professional standards of practice for four (Resident #1, Resident #3, Resident #5 and Resident #6) of five residents reviewed for oxygen in that:-The facility failed to have a system in place of how to ensure the oxygen concentrators were maintained to ensure that Resident #1, Resident #3, Resident #5 and Resident #6 received oxygen at the prescribed flow rates.- The facility failed to ensure Resident #3's oxygen was administered continuously as ordered by the physician.-The facility failed to ensure Resident #5's oxygen was administered at 2 liters per minute instead of 1.5 liters per minute via nasal cannula as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #3) of 6 residents reviewed for pharmacy services.- The facility failed to ensure timely acquisition of Resident #3's Pregabalin and was not administered per physician's ordersThe failure could place residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered.

Inspectors wroteBased on observation, interviews and record review the facility failed to have an adequately equipped system that allowed residents to call for staff assistance through a communication system for 2 of 2 call light systems viewed for resident call system. The facility failed to ensure that residents' call lights in Rooms 254 and room [ROOM NUMBER] were functioning properly. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interviews and record reviews, the facility failed to consult with the resident's physician when there was a significant change in the resident's mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #3) of six residents reviewed for physician notification.-The facility failed to immediately consult with the Nurse Practitioner when Resident #3 was threatening to throw herself on the floor. This failure could place residents at risk of delayed medical treatment. Findings Included:Closed record review of the admission Record dated 01/23/26 for Resident #3 revealed, original admission date 12/24/25 and re-admission date 01/22/26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #5) of 4 residents reviewed for enteral feeds. The facility failed to ensure Resident #5's water with enteral feed was administered according to physician's orders. This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 1 (Resident #1) of 6 residents reviewed for medical records. -The facility failed to ensure LVN B documented in the Nurse's Notes on 1/12/26 resident assessment when Resident #1 had a change in condition. - The facility failed to ensure LVN E documented in the Nurse's Notes on 1/12/26 when she called the physician to confirm medications orders for Resident #1 upon admission to the facility and when Resident #1 was transported to the hospital on [DATE] due to a change in condition. This failure could place residents at risk of resident's records not reflecting accurate and complete information.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for _3 of 18_ residents (Resident #1, #4, and #48) reviewed for call lights. The facility failed to ensure resident call lights were within reach for Residents #1, #4, and #48 on 01/06/2026. This failure placed residents at risk of having their needs unmet when they are unable to contact staff.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the resident was offered sufficient fluid intake to maintain proper hydration and health for 4 (Resident #39, #48, #53, #87) of 4 residents reviewed for access to hydration. The facility failed to ensure staff provided access to hydration and provide fresh water and ice at bedside for Residents (#39, #48, #53, #87) on 01/06/2026 at 10:42 AM, 1:31 PM, 1:49 PM, and 4:02 pm. As per facility policy, residents should be encouraged to consume fluids (6-8 glasses per day) and there was no regular tracking of fluids being provided to residents in-between meals and during periods of physical activity. This deficient practice could place residents who are dependent on staff to become dehydrated by not having access to hydration.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 4 (Resident #4, Resident #7, Resident # 28, and Resident #77) of 12 residents observed for oxygen management. The facility failed to place an oxygen concentrator air filter on the concentrator for Resident #4, while the oxygen was in use, there was no filter in place on 01/06/2026. The facility failed on 01/06/2026 to clean the oxygen concentrator air filter for Resident #7, Resident #28 and Resident #77, while the oxygen was in use, concentrators were observed with air filters that appeared to have dust, strands of hair and lint collected on them. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. - The facility failed to maintain safe consumable produce as evident by 5 unwrapped and aged lettuces observed on 01/06/2026 8:36 AM - The facility failed to maintain safe consumable produce as evident by 2 visibly molded tomatoes observed on 01/06/2026 at 8:37 AM - The facility failed to maintain safe consumable produce as evident by cross contaminating a box of potatoes with an overripened banana observed on 01/06/2026 at 8:53 AM - The facility failed to ensure staff were following meal service policy as evident by improper meal service handling in the dining room with staff member grabbing residents' cups from the upper portion on 01/06/2026 at 11:57 AM by CMA E. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented and systematically organized for one (Resident #1) of two resident records reviewed for wound care. -The facility failed to ensure LVN L documented Resident #12's bruise by appearance, size, color, and site, when informed of the bruise. -The facility failed to ensure LVN M documented the DON and Administrator were notified of Resident #12's acute change, an observed bruise on the left eye. -The facility failed to ensure an incident report was made once staff was made aware on 01/05/2026, of Resident #12's allegation of a fall that allegedly occurred the night of 01/03/2026 or 01/04/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 12 residents (Residents #4, #7, #28, and #73) reviewed for transmission based precautions. The facility failed to ensure Resident #4, and 73's nasal canula was placed correctly on resident on 01/06/2026. The facility failed to ensure that Resident #7 and #28's foley catheter bag remained off the floor on 01/06/2026. These deficient practices could place residents at risk of exposing them to care that could lead to the spread of infections.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff consistent with their expected roles for 3 of 8 employees (The Administrator, The Dietary Manager, and LVN N) reviewed for personnel files. -The facility failed to ensure The Administrator and LVN N had completed communication training on 01/08/2026 at 1:48 PM when staff had been employed for several months; the Administrator was employed for 2 and a half months and LVN N was employed for 5 and a half months. -The facility failed to ensure the Dietary Manager, the Administrator, and LVN N had completed orientation training for Restraint Reduction on 01/08/2026 at 1:48 PM when staff had been employed for several months; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility treated each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents for 1 of 8 residents (Resident #87) reviewed for dignity. The facility failed to provide a privacy bag for Resident #87's foley bag. It was observed that the foley bag was visible on Resident #87's bedframe from the hallway on 01/06/2026 at 1:46 PM. This failure placed the residents at risk of poor self-esteem and decreased self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 10 residents (Residents #12) reviewed for abuse/neglect. The facility failed to investigate an allegation of neglect of Resident #12 on 01/05/2026 when Resident #12 was noted to have bruising to the left eye by LVN L and LVN M. Resident allegedly fell off the bed during an unknown night. These failures could place residents at risk for abuse, neglect, emotional distress, physical harm, and trauma.the

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of twelve residents (Resident# 6, and Resident #80) reviewed for ADL care. -The facility failed to ensure Resident #6 face was clean and free of facial hair on 01/06/26.-The facility failed to ensure Resident #80's fingernails were clean and free from debris on 01/06/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs. Record review of Resident #6's face-sheet dated 01/07/2026, revealed a [AGE] year-old female with initial admission date 05/20/2022, and re-admission date 08/11/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 (Resident #4) of 8 Residents reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. -The facility did not ensure that Resident #4 was provided with repositioning at least every two hours on 01/06/2025, Resident #4 was observed sitting up in his bed, facing the TV placed in front of his bed at the following times: 9:31 AM, 11:38 AM, 1:40 PM, and 3:00 PM. This failure could affect the residents requiring staff assistance for repositioning, placing them at risk for skin breakdown and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 facility dumpster. The facility failed to ensure the facility dumpster was closed by the 2 top lids and 2 sliding metal side doors on 01/07/2026 at 1:15 PM. The facility failed to ensure the surrounding area was free of debris as observed on 01/07/2026 at 1:17 PM where a mattress, hospital bed, and wooden pallet were abandoned on the exterior of the facility dumpster. This failure could result in an infestation of rodents and insects in the dumpster and facility.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 6 residents (Resident #12 and Resident #13) reviewed for dignity with meal assistance. The facility failed to ensure that Residents #13 and #14 were assisted with eating while staff were seated at eye level. This failure posed a risk of inadequate monitoring during feeding, which could result in, reduce dignity during mealtime, and hinder the ability to respond promptly to signs of distress.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #14) reviewed for care plans. The facility failed to the implement a comprehensive person-centered care plan that addressed Resident #14's history of wandering. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interview and record review the facility failed to ensure records were maintained that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure that LVN A completed a personal inventory sheet for Resident #1 upon admission. This failure posed a risk of loss, misplacement, or unaccounted personal belongings, which could lead to resident dissatisfaction, grievances, and limited the facility's ability to verify personal items during the resident's stay or upon discharge.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide treatment and care based on the comprehensive plan of care for 1 (Resident #1) of 5 residents reviewed for pressure ulcers. The facility failed to provide and assess care on 11/01/24 for Resident #1's Arterial ulcer to her right foot big toe. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to ensure that the residents environment remains free of accidents hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #4) of 4 residents reviewed for accidents. The facility failed to make sure the fall mat for Resident #4 was in good condition and not torn or ripped apart. This failure could place residents at risk of falling and injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #5) of 4 residents observed for oxygen management. Resident #5 was being given oxygen without physician orders from 10/20/24-10/25/24. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that resident had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for all facility residents (65) and their families. -The facility failed to make the results of the most recent survey of the facility available to residents, and family members and legal representatives of residents. This failure placed residents and family members and legal representatives of residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan, that met professional standards of for 1 of 10 resident (Resident #6) reviewed for services that met professional standards. -The facility failed to ensure licensed staff administered medications via nebulizer according to accepted standards of clinical practice by not assessing the respiratory status for Resident #6 before and after treatment. -The facility failed to ensure LVN B performed hand hygiene and/or used PPE while administering medications via nebulizer. This failure could place residents at risk for inaccurate drug administration, not receiving the care and services to meet their individual needs, and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #8 and Resident #6) of 2 residents observed for oxygen management. -The facility failed to keep the oxygen machine and filters clean for Resident #6. --The facility failed to ensure licensed staff administered medications via nebulizer according to accepted standards of clinical practice by not assessing the respiratory status for Resident #6 before and after treatment. -The facility failed to post oxygen sign on in Resident #8's door. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 (2nd Floor) of 2 medication rooms reviewed for medication storage and 32(Residents #1, and #48) of 10 residents reviewed for medication administration. -The facility failed to administer Resident #1 Gabapentin according to physician's order. - The facility failed to dispose medications for Resident #48 when medication was not administered as ordered. - The facility failed to ensure LVN B signed off on the Controlled Drugs-Count Record after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at the change of shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 14% based on 4 errors out of 27 opportunities, for three residents (Resident #1, Resident #41, and Resident #48) of ten residents observed for medication administration, by two (LVN A and LVN B) of seven staff reviewed for medication errors. -The facility failed to ensure LVN A administered medication to Resident #1 according to physician's orders. -The facility failed to ensure LVN A administered medication to Resident #41 according to physician's orders. -The facility failed to ensure LVN C administered medications to Resident #48 according to physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with manufacturer's specifications for of 2 of 3 medication carts (Hall 101-124 and Hall 210-244) reviewed for medication storage and handling of medications; 1 (Hall 245-276) of 5 medication carts reviewed for controlled substances; 1 of 1 medication room reviewed for storage of medications. -The facility failed to ensure licensed staff did not store medications after they had been poured in medication cart. -The facility failed to ensure Licensed Staff signed the form after counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming nurse at the change of shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 diet test trays reviewed for food temperatures. -The facility failed to maintain food hot on diet serve test trays. -This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. 1. - The facility failed to keep the tile floors free of dust, dried stains, and disposable cups on the floor. 2. - The facility failed to keep the refrigerator shelve free of dried food particles. 3. - The facility failed to keep food containers stored in the kitchen free of dust and food particles. 4. - The facility failed to discard perishable foods stored in the walk-in refrigerator. The multiple Jalapeno peppers had wrinkles, and one Jalapeno pepper had a black substance; Cabbage was mushy, and the edges of the leaves were brown. 5. - The facility failed to keep the kitchen equipment free of grease build-up and food particles. 6. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain accurate medical records on each resident in accordance with accepted professional standards and practices that were: Complete; Accurately documented; Readily accessible; and systematically organized for 2 (resident #55 and #60) of 3 residents. The facility had incomplete documentation for the treatment of Resident #55 and #60's restorative therapy care. This failure could delay identification of problems with the restorative therapy, resulting in a delay in treatment.

Inspectors wroteBased on interviews and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take actions aimed at performance improvement and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained. The facility failed to address concerns regarding foods that were not kept hot when served to the residents. This failure could place residents at risk of weight loss and unresolved dietary concerns.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the QA committee developed and implemented appropriate plans of action to correct identified dietary concerns reported in the group interviews and Satisfaction Survey completed by the consultant dietitian. The facility failed to ensure that the QA committee developed a plan of action to ensure the food complaints or grievances were addressed and resolved. This failure could place residents at risk of weight loss and unresolved dietary concerns.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #60, Resident #55, and Resident #6) of fifteen residents observed for Infection Control. -CNA D failed to perform hand hygiene between passing out food trays in between residents. - CNA D failed to perform hand hygiene between helping a Resident #60 out of bed to sit and eat and providing feeding assistance to Resident #55. -The facility failed to ensure licensed staff washed hands between residents when administering medication. -The facility failed to ensure LVN B performed hand hygiene and/or used PPE while administering medications via nebulizer treatment. [...]

Inspectors wroteBased on observations, and interviewsthe facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment; and 1 of 1 laundry room reviewed for safe operating equipment. -The facility failed to maintain the stove in operational condition. -The facility failed to maintain washers and dryers in operational condition. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observations, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in three of five halls and 1 of 1 kitchen and 1 of 2 medication rooms reviewed for environmental conditions. - The facility failed to maintain resident halls and kitchen free of dust. --The facility failed to ensure there were paper towels in the towel dispenser in the medication room. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered plan of care for 2 (Residents #41, and #48) of 10 residents reviewed for drug regimens. -The facility failed to ensure Resident #41 and Resident #48 were administered medication with meals according to physician's orders. These failures placed residents at risk of not receiving medications according to manufacturer specifications placing them at increased risk of adverse drug effects and decline in their health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with Urinary Incontinence received appropriate treatment and services to prevent Urinary tract infections for 1 (Resident #5) out of 3 residents reviewed for quality of care. 1. The facility failed to ensure Resident #5's indwelling catheter tubing was not laying on the floor and he had a privacy bag on 08/07/2024 . 2. The facility failed to ensure Resident #5's subpubic catheter was properly secured to a leg strap on 08/08/2024 . This failure could place residents at risk of a Urinary Tract Infection and injury.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice of 1 (Resident #1) of 5 reviewed for quality of care: -The facility failed to follow physician orders to assess vital signs every shift for Resident #1 for several shifts. This failure could cause a decline in residents' health if vital signs are not being monitored as ordered.

Inspectors wroteBased on interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 5 reviewed for medication orders. The facility failed to administer 3 medications to Resident#1 per physician orders on several shifts. This failure could affect residents and cause a decline in health if medications are not given as ordered.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. -The facility failed to document vital signs in Resident #1's clinical record for several shifts. Vital signs were blank on his vitals signs data sheet and TARs. This failure could cause a decline in health in residents if vital information is not being documented accurately.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had clean bath linens for 2 (Resident #41 and Resident #24) of 16 residents reviewed for bath linens. The facility failed to ensure that Residents #41 and #24 had bath towels available to dry off with when bathed. This failure could put residents at increased risk of discomfort and embarrassment due to not having bath towels to dry off with after bathing.

Inspectors wroteBased on observation, interview, and record review, the faciality failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain and/or maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 (Resident #19) of out 8 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #19 preferences of showers. This failure could place residents at risk of decreased quality of life due to not having their treatment and preferences met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs to meet the needs of the residents for 1(2nd floor) of 2 medication storage rooms and 1(1st floor) of 3 medication carts. -1st floor medication cart had expired medications. -2nd floor medication room had expired medications. This failure could cause a decline in health in residents if expired medications were to be given.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. The facility failed to properly seal and date food in the freezer, refrigerator and dry food storage. The facility failed to dispose of expired items in the food prep areas. This failure places residents who eat food prepared by the facility at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 out of 1 trash containers reviewed for food safety requirements. The facility failed to have garbage cans without a lid in the kitchen. This failure could affect residents by placing them at risk of food born illness, illnesses, or be provided with an unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical equipment in safe operating condition for one of three washing machines and two of four dryers reviewed for being in operating condition. The facility failed to repair one washing machine and two dryers for a period of one month. This failure placed residents at risk of not having enough towels to dry?with after showers.

Inspectors wroteBased on interview and record review the facility failed to include effective communications as mandatory training for direct care staff for 11 (DON, ADON A, LVN C, LVN D, CNA H, CNA I, CNA J, Social Worker, SLP L, O.T. M, and P.T. N) of 17 direct care staff reviewed for training on effective communication The facility failed to ensure direct care staff received training on effective communication?for the DON, ADON A, LVN C, LVN D, CNA H, CNA I, CNA J, the Social Worker, SLP L, OT M, and PT N. This failure could put residents at increased risk of not having a way to effectively communicate their wants or needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that all staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents for 10 (DON, ADON A, ADON B, LVN D, CNA F, CNA J, the Activity Director, the Maintenance Supervisor, O.T. M, and P.T. N) of 21 employees reviewed for training on the rights of the resident and the responsibilities of a facility to properly care for its residents The facility failed to ensure theDON, ADON A, ADON B, LVN? D, CNA F, CNA J, the Activity Director, the Maintenance Supervisor, O.T. M, and P.T. N received training on the rights of the resident and the responsibilities of a facility to properly care for its residents This failure could put residents at increased risk of not having their rights respected or not receiving proper care.

Inspectors wroteBased on interview and record review the facility failed to ensure that training was provided regarding dementia management for 9 (Administrator, DON, ADON A, ADON B, LVN C, LVN D, CNA G, CNA H, and CNA J) of 12 employees reviewed for training on dementia management. The facility failed to ensure the Administrator, DON, ADON A, ADON B, LVN C, LVN D, CNA G, CNA H, and CNA J received training on dementia management. This failure could put residents at increased risk of improper management of dementia-related issues.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #214) of eight residents reviewed for physician notification. The physician was not notified that Resident #214 had a fall on 08/25/23 and complained of pain to the left hip. This failure put residents at risk of delayed medical treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 8 residents (Resident # 165) reviewed for enteral feeding. -Resident #165's enteral feeding formula was not labeled with time of administration, date it was hung, and rate that formula was given. This failure could place residents receiving enteral feedings at risk of malnutrition if feedings were to be given incorrectly.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #28) of 2 residents reviewed for peripheral intravenous care. - The facility failed to date the intravenous dressing site of Resident #28's central line when it was changed. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions for 1 (Residents #52) of 6 residents whose drug regimens were reviewed. Resident #52 was receiving an antipsychotic for which no gradual drug reduction had been attempted. This failure puts residents at increased risk of experiencing side effects as a result of taking unnecessary medications.